NOTICE TO PLAN PARTICIPANTS

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2 NOTICE TO PLAN PARTICIPANTS The organization that sponsors your student health plan has certified that it qualifies for a temporary enforcement safe harbor with respect to the Federal requirement to cover contraceptive services without cost sharing. During this one-year period, coverage under your student health plan will not include coverage of contraceptive services. Your student health insurance coverage, offered by Deseret Mutual, is not required to meet, and does not meet, the minimum standards for the restrictions on annual dollar limits required by the health care reform law for non-student health insurance. The annual dollar limits ensure that you have sufficient access to medical benefits throughout the annual term of the policy. Restrictions for annual dollar limits for non-student health insurance coverage are $1.25 million for policy years beginning before September 23, 2012; and $2 million for policy years beginning on or after September 23, 2012 but before January 1, The health care reform law restricts annual dollar limits in student health insurance coverage to $100,000 for policy years before September 23, 2012, and $500,000 for policy years beginning on or after September 23, 2012, but before January 1, Your student health insurance coverage applies an annual limit of $250,000 per person per policy year for services outside of the Student Health Center. If you have any questions or concerns about this notice, contact Deseret Mutual. Be advised that you may be eligible for coverage under a group health plan of your parent s employer or under a parent s individual health insurance policy if you are under age 26. Contact the plan administrator of your parent s employer plan or your parent s individual health insurance issuer for more information about other potential coverage BYU-Idaho Student Health Plan i

3 ii BYU-Idaho Student Health Plan

4 Who to Contact For information that is not included in this brochure, or if you have a question, please contact the following offices. Frequently Asked Questions: See pages 38 to 39 of this handbook Enrollment and Premium Information: Regular, Away-from-Campus, and Extended Coverage Student Health Center Student Health Center Pharmacy Deseret Mutual Enrollment Team P.O. Box Salt Lake City, Utah Appointments & Referrals 100 Student Health Center BYU-Idaho Rexburg, ID Student Health Center BYU-Idaho Rexburg, ID Deseret Mutual Customer Service and Preauthorization: Deseret Mutual s Preferred Provider Network: Find a Contracted Medical Provider: 60 East South Temple P.O. Box Salt Lake City, Utah Southeast Idaho & Utah: Deseret Mutual Contracted Providers or (click on Find a Provider ) Hawaii: MDX Contracted Providers Washington State: First Choice Health Network, Inc or Other Areas (for services through December 31, 2012): All other states: First Health National PPO or Other Areas (for services on or after January 1, 2013): All other states: UnitedHealthcare Options PPO Access the Student Health Plan Handbook: To contact Deseret Mutual online, go to: BYU-Idaho Student Health Plan iii

5 I M SICK! WHAT SHOULD I DO? Heart attack Is it an emergency? Severe bleeding Loss of consciousness Convulsions Temperature above 104 F Severe, sudden onset of symptoms that threaten to impair bodily functions Get help immediately! Facility Copayment Urgent Care $25 Emergency Room $50 Is it a non-emergency? Family medicine Orthopedics Internal medicine Pediatrics X-ray and Pharmacy lab services Go to the Student Health Center (SHC) Call for an appointment at For answers to your medical questions, go to You will pay $10 up front, plus 20% of the remaining bill. If you need to be treated immediately, but the SHC isn t open, go to the nearest urgent care facility or emergency room. After the Emergency Call Deseret Mutual at : If you re admitted to the hospital or receive emergency care in a physician s office after business hours, call within two business days to preauthorize Call before you receive any follow-up care outside of the SHC What do I pay to a provider outside of the SHC? That depends on the services you receive. For more information, see pages 9 to 19 of the Student Plan Handbook. What if the SHC can t treat me? The SHC will refer you to a contracted medical provider in the community. They will also contact Deseret Mutual to preauthorize the services you re referred to receive. What if an outside provider recommends additional care? Before receiving any care that is not specified in an SHC referral, call Deseret Mutual. Preauthorization to see an outside provider does not guarantee payment for every treatment a provider recommends. Make sure you understand plan guidelines, benefits, and exclusions before you receive services. For more information, see Frequently Asked Questions on pages 38 to 39 iv BYU-Idaho Student Health Plan

6 BYU-IDAHO STUDENT HEALTH PLAN SUMMARY OF BENEFITS Student Health Center Referrals Preauthorization Copayments Deductibles Maximum Benefit Catastrophe Protection You and your covered dependents must use the Student Health Center (SHC) as your primary care provider. Physician services at the SHC are paid at 100% after your $10 copayment. Additional services, such as lab tests, X-rays, etc., are covered at 80%. Any service provided outside of the SHC requires a referral from the SHC and preauthorization from Deseret Mutual. If you or your covered dependents need to see a specialist outside of the SHC, you must obtain a referral from the SHC before making an appointment with the specialist. This referral from the SHC will automatically initiate a request for preauthorization with Deseret Mutual. You must preauthorize all services outside of the SHC, except emergency room visits and well-baby care. If you are referred by the SHC, the preauthorization is requested automatically. Otherwise, you must contact Deseret Mutual at before you receive the medical care (see page 8). SHC: $10 for physician services. Outside of the SHC: $25 per service for physician, urgent care, and other outpatient care; $50 for hospital emergency room visits; $300 per hospital admission. For married student plans, there is a $750 deductible per person with a $1,500 policy maximum. For nonstudent spouses, there is a $4,750 maternity deductible plus all applicable copayments. There is a maximum benefit of $250,000 per person per policy year for services outside of the SHC. There is a maximum coinsurance of $5,000 per person per policy year for services outside of the SHC. If your share of eligible coinsurance reaches $5,000, your benefits for the remainder of the calendar year are paid according to the catastrophe protection of the plan, up to your $250,000 annual plan maximum. For details, see page 21. Explanation of Covered Expenses Plan payments are subject to maximum allowable charges, determined by Deseret Mutual (see page 36). Covered Services Contracted Provider Non-Contracted Provider Ambulance: Licensed land or air transport 80% of allowable charges after copayment 50% of allowable charges after copayment Ambulatory Surgical Center: Outpatient surgery, services, & supplies Diagnostic X-ray & Lab Services: CT, MRI, ultrasound, lab, and pathology Durable Medical Equipment: Rental or purchase of DME (see page 14) Emergency Care: Emergency room services & supplies Home Health Care: Services & supplies from a home health agency Hospital Medical Services: Semi-private room, surgical services & supplies, outpatient medical care 80% of allowable charges after copayment 50% of allowable charges after copayment 80% of allowable charges after copayment 50% of allowable charges after copayment 80% of allowable charges after copayment 50% of allowable charges after copayment 80% of allowable charges after copayment 80% of allowable charges after copayment 50% of allowable charges after copayment 80% of allowable charges after copayment 50% of allowable charges after copayment Maternity Care*: Hospital and ancillary services Physician office visits (See pages 12 to 13) 80% of allowable charges after copayment 80% of allowable charges after $25 copayment per visit to a maximum of $250 for routine care 50% of allowable charges after copayment 50% of allowable charges after $25 copayment per visit to a maximum of $250 for routine care Outpatient Therapy: Chemotherapy, dialysis, mental health, physical, and radiation therapy Physician Medical Services: Office visits, hospital visits, surgeon, surgical assistant, and anesthesiologist Prescription Drugs 80% of allowable charges after copayment 50% of allowable charges after copayment 80% of allowable charges after copayment 50% of allowable charges after copayment 80% for covered brand-name and generic drugs at the SHC or network pharmacies Preventive Care (see table on page 17) 100% of allowable charges; no copayment 50% of allowable charges after copayment *Maternity coverage is included for all students / policyholders. This summary of benefits provides a brief review of plan benefits. For complete details of coverage, including limitations and exclusions, please read this entire Student Plan handbook. For more information, see Frequently Asked Questions on pages 38 to BYU-Idaho Student Health Plan v

7 BYU-IDAHO STUDENT HEALTH PLAN SUMMARY OF MATERNITY BENEFITS General Information Maternity coverage is included for all students / policyholders. This summary of benefits provides a brief review of plan benefits. For complete details of coverage, including limitations and exclusions, please read this entire Student Plan Handbook. Preauthorization Contact the Student Health Center before you begin your prenatal care with an OB/GYN or Certified Nurse Midwife. To maximize your benefits, you should also call Deseret Mutual at to preauthorize care. In addition, you must preauthorize hospital stays of more than two days for a vaginal delivery or four days for a cesarean section delivery. Call Deseret Mutual before your stay is extended. Copayments Physician / Nurse-Midwife Services: $25 per visit, up to a total of $250 for routine care Hospital Services: $300 per hospital admission. Newborn infants are considered a separate admission from the mother and will also be subject to the copayment, if they are enrolled in the Student Health Plan. Deductibles Married students: $750 per person up to a total of $1,500 per policy Non-student spouses: $4,750 plus all applicable copayments (see Non-student Spouses below). Non-student Spouses Non-student spouses must pay a deductible of $4,750 before maternity expenses will be covered. After meeting this deductible, benefits are paid according to normal plan provisions (see page 8). Covered Services Contracted Provider Non-Contracted Provider Hospital Services 80% of allowable charges after copayment 50% of allowable charges after copayment Physician / Nurse-Midwife Services 80% of allowable charges after copayment 50% of allowable charges after copayment Preventive Care (See table on page 17) 100% of allowable charges; no copayment 50% of allowable charges after copayment This summary of benefits provides a brief review of plan benefits. For complete details of coverage, including limitations and exclusions, please read this entire Student Plan handbook. For more information, see Frequently Asked Questions on pages 38 to 39. vi BYU-Idaho Student Health Plan

8 CONTENTS Introduction University Insurance Requirement Changes for Prescription Benefit Preventive Services Extended Coverage Option Enrollment Enrolling Yourself Enrolling Your Family Changing Enrollment Midyear Waiving Enrollment Eligibility Coverage Coverage Options While You re Away from BYU-Idaho Away-from-Campus Coverage Option Extended Coverage Option Coverage Periods Coverage at Other Church Universities Premiums How the Plan Works Overview Insurance Identification Card Copayments and Office Visit Fees Plan Benefits and Coinsurance Maximum Plan Benefit BYU-Idaho Student Health Plan Table of Contents

9 Deductibles Preauthorization Student Health Center Available Services Payment for Services Operating Hours Services Outside of the SHC Deseret Mutual s Preferred Provider Network Emergencies Life-threatening Emergencies Other Medical Emergencies Follow-up to Emergency Care Submitting Claims for Payment Claims Payment Timelines Catastrophe Protection Repatriation of Remains Exclusions Subrogation Notification of Benefit Changes Fraud Policy Statement Legal Notice Important Dates Internal Claims Procedures Appeals of Initial Internal Adverse Benefit Determination Your Right to an Independent External Review Definitions Frequently Asked Questions Index Table of Contents BYU-Idaho Student Health Plan

10 Introduction Having good health is important for you to achieve your goals at BYU-Idaho. And having adequate medical coverage is important to your good health. Without adequate coverage, unexpected expenses could alter your future dramatically. An accident, illness, or hospitalization could result in a financial burden to you, your family, and the community. For this reason, BYU-Idaho requires all students to have adequate medical coverage. To help provide this coverage, the BYU-Idaho Student Health Plan was designed to offer a wide range of benefits for students, spouses, and their children at a relatively low cost. This plan is administered by BYU-Idaho and Deseret Mutual Benefit Administrators (Deseret Mutual). This handbook will provide you with a summary of plan benefits, as well as information about how the plan works. Please review this information carefully. To receive the benefits available to you, it s your responsibility to become familiar with the plan provisions and guidelines. Exceptions to the plan s contractual provisions cannot be granted. University Insurance Requirement BYU-Idaho requires all matriculating students to have adequate medical coverage in the Rexburg area as long as they have continuing student status. That means you must have coverage the entire time you are a continuing BYU-Idaho student, including during any semesters you are off-track or other short-term breaks from classes. To satisfy this requirement, you will be enrolled in the Student Health Plan automatically when you first enroll for classes. Your enrollment will remain in effect until you graduate from BYU-Idaho or lose your continuing student status, whichever comes first. You will also be covered by the plan while you are traveling to and from school, before or after a semester or block. If you are married, your spouse and children will not be enrolled in the plan automatically, but you may enroll them by completing a Dependent Coverage Enrollment Form. If your spouse is also a student, he/she will be enrolled automatically. Changes for 2012 Prescription Benefit BYU-Idaho is pleased to announce that by pairing with Deseret Mutual and VRx pharmacy services, all students covered by the Student Health Plan now have access to a prescription drug benefit. With this benefit, you can access a wide array of generic prescription drugs as well as insulin. At the BYU-Idaho Student Health Center (SHC) pharmacy, the plan pays 80% and you pay 20%. You may also buy prescriptions at all pharmacies in the VRx pharmacy network. At these covered network pharmacies, the plan pays 80% and you pay 20%. For more information, see page 16. Preventive Services Beginning this academic year, the Affordable Care Act (otherwise known as health-care reform ) mandates a number of preventive services to be covered by the Student Health Plan, with no cost to you when you see a contracted (or network ) provider. For a list of the covered preventive services, see page 17. Extended Coverage Option Because of federal regulations in the Affordable Care Act, the length of time that former students can remain in student health plans has been decreased. This means the period you may enroll in Extended Coverage is now 90 consecutive days after you graduate, withdraw, or otherwise lose your continuing student status BYU-Idaho Student Health Plan 1

11 Enrollment Enrolling Yourself If you are a continuing student, you will be enrolled in the Student Health Plan automatically for individual coverage at the beginning of your first semester/block at BYU-Idaho. Generally, your enrollment will remain in effect until you graduate or withdraw from BYU-Idaho (for coverage periods, see page 5). As long as you are a continuing student, your individual enrollment will renew at the beginning of each fall semester. When you enroll in the plan, you must enroll for the entire school year. If you later obtain health coverage that meets BYU-Idaho s insurance requirement, you may waive Student Health Plan coverage (for more information, see page 3). If you don t enroll for classes for one semester but intend to return the following semester, you must maintain your enrollment in the plan. If you are leaving school for two or more semesters, you may enroll in Extended Coverage (for more information, see page 4). Enrolling Your Family BYU-Idaho does not require your eligible dependents to be enrolled in the Student Health Plan. However, if you want to enroll your eligible dependents, you may change your enrollment from individual to family coverage at the beginning of your first semester/block, or at the beginning of each fall semester thereafter. If you enroll your family, their enrollment will generally remain in effect until you graduate or withdraw from BYU- Idaho (for coverage periods, see page 5). BYU-Idaho will renew enrollment for your family at the beginning of each fall semester based on their enrollment for the previous semester. If you want to change your family s enrollment, remember to notify the insurance personnel at the Student Health Center. To enroll your family, go to the insurance personnel at the Student Health Center. Enrollment forms are due during the first week of classes. If you are a new student, you must return the form during the first week of your first semester/block. If you are a continuing student, you must return the form during the first week of the next fall semester. Remember, if you don t enroll your dependents at the beginning of your first semester/block or at the beginning of the fall semester, you can t add them to your coverage midyear. You must wait until the next fall semester unless you meet one of the special circumstances outlined below. Changing Enrollment Midyear If you enroll for individual coverage and don t enroll your dependents, you cannot add them to your coverage midyear. However, you have 60 days to enroll new family members acquired through marriage, birth, or adoption. Coverage for a new spouse or stepchildren will begin the first month following your marriage date. Newborns or newborn adopted children are covered on their birth dates; adopted children older than 60 days are covered effective the date they are placed with you. After adding a dependent through birth or adoption, any additional premium must be paid within 31 days after you have received notice of the billing. In the case of an adopted child, placed means physical placement in the care of the adoptive subscriber or other member of the covered group. When physical placement is prevented because the child requires care in a medical facility, placed means when the adoptive subscriber or other member of the covered group signs agreements for adoption and assumes financial responsibility for the child. If you waive enrollment in the plan (or if you don t enroll your dependents) because you have other group coverage, but you later lose that coverage, you will be enrolled in the Student Health Plan for the semester/block when coverage was lost. If you want to enroll your dependents as well, you must apply within 60 days of losing the other coverage. If you don t enroll them within this 60-day window, you must wait until the beginning of the following fall semester. 2 BYU-Idaho Student Health Plan

12 If you enroll in the Student Health Plan, but you later obtain other coverage that meets BYU-Idaho s requirements, you may waive enrollment in the Student Health Plan at the beginning of the next semester/block. To do so, submit an online waiver at before the beginning of the semester/block. Or you may complete a form and submit it to the insurance personnel at the Student Health Center. You may also drop dependents from coverage at the beginning of any semester/block. Waiving Enrollment You may waive Student Health Plan coverage if you are covered in the Rexburg area by your parent s insurance or by a group insurance plan provided by your employer or your spouse s employer. Other private insurances will not be accepted. If you have an unusual situation, you may submit a Petition to Waive Student Insurance by going to You must submit waiver information online or to the insurance personnel at the Student Health Center before the insurance deadline for each semester (one week after the semester begins). If your coverage from another insurance plan ends while you are attending BYU-Idaho, contact the insurance personnel at the Student Health Center immediately. You must either enroll in the Student Health Plan within 63 days after the coverage ends or provide verification of coverage from another qualified plan. Eligibility The following individuals are eligible to enroll in the Student Health Plan. Students: You will be enrolled in the plan automatically if you are a matriculating student, unless you certify that you meet the waiver requirement (see above). Recent Students: Upon loss of continuing student status, you may continue enrollment in the plan for up to nine months by enrolling in Extended Coverage (see page 4). Dependents: If you enroll in the plan, you may also enroll your eligible dependents, including: Your spouse. Your spouse is a person of the opposite sex who is your legal husband or wife Your eligible children. Eligible children are your unmarried children who are younger than 26 including: Natural children (including infants from date of birth), legally-adopted children, and children appointed by a court of law to your custody or your spouse s custody. In the case of a child who is committed by a court of law to your custody or your spouse s custody, you must submit a copy of the certified court order granting the adoption, custody, or guardianship A child placed with you under the direction of a licensed child placement agency and for which you are the legal guardian Your unmarried child who is 26 or older and incapable of self-support because of mental or physical incapacity that existed before the child reached 26, and who is primarily dependent upon you for support Your stepchild (child of your spouse) younger than 26. If the stepchild is younger than 18, your spouse must have a court order granting full or partial custody Coverage Coverage Options There are three coverage options within the Student Health Plan. You will be enrolled in the appropriate option, based on your student status BYU-Idaho Student Health Plan 3

13 If you are... Your coverage option is... Admitted as a continuing student and enrolled in classes Regular On-Campus coverage Enrolled in an internship required for your degree or on tour as part of a BYU-Idaho program Admitted as a continuing student but taking a semester/block off Graduated or withdrawn from school Please be aware that benefits and plan requirements may be different in each option. These differences are noted in this handbook. Remember, you must preauthorize all services received outside of the SHC, other than emergency and well-baby care. While You re Away from BYU-Idaho In the following instances, you may continue your Student Health Plan coverage even while you are away from the BYU-Idaho campus. Short Breaks from School: If you enroll in the plan for the academic year and then decide to take a semester off, but you don t withdraw from BYU-Idaho or otherwise lose your continuing student status, you will be covered by the Away-from-Campus option during that semester. For more information, see below Internships and Student Tours: If you enroll in the plan and you participate in an internship required by your department or you travel as a member of a BYU-Idaho student tour, you will be covered by the Away-from- Campus option during that semester. For more information, see below Missions: If you leave BYU-Idaho to serve a mission, you will not be covered by the plan during that time. You may re-enroll when you return to BYU-Idaho After Leaving BYU-Idaho: Within certain limitations, you may continue enrollment in the Extended Coverage option after you graduate or withdraw from BYU-Idaho. For more information, see below Away-from-Campus Coverage Option This option provides coverage for students who are temporarily away from campus and therefore do not have access to the SHC. If you are enrolled in the Student Health Plan for the academic year, you will be enrolled in the Awayfrom-Campus option while you: Participate in an internship Travel as a member of a BYU-Idaho academic tour or performing group on tour Take a temporary break from enrollment in classes on campus (such as an off-track semester or taking the a semester off), but do not withdraw from the University or otherwise lose your continuing student status If you have enrolled your dependents in the plan, they will also be covered by this option for as long as you are. While you re enrolled in this option, you must receive medical care at the SHC if you are in the Rexburg area. If you are away from Rexburg, you may receive your medical care from any qualified, appropriately licensed medical provider. However, it will be to your advantage to use providers who are part of Deseret Mutual s national Preferred Provider Network whenever possible. For more information about the Preferred Provider Network, see page 19. You must still preauthorize any care you receive outside of the SHC, other than emergency and well-baby care. Extended Coverage Option Away-from-Campus coverage (see below) Away-from-Campus coverage (see below) Extended Coverage (optional, see below) Your Student Health Plan coverage ends the day before the beginning of the next semester after you graduate, withdraw, or otherwise lose your continuing student status. If you were enrolled in the plan during your last semester 4 BYU-Idaho Student Health Plan

14 and would like to continue coverage after you leave school, you may enroll in Extended Coverage for up to 90 consecutive days. To enroll, pick up an Extended Coverage enrollment form from the insurance personnel at the Student Health Center and submit it to the Membership Team at Deseret Mutual before the end of your last semester/block at BYU- Idaho. You must also pay your premium for the first month of coverage. You must renew your coverage on a month-to-month basis. To do this, submit an enrollment form to the Membership Team at Deseret Mutual before the end of the previous month. If you don t submit your renewal application within five working days of the end of the previous month, it will not be accepted. Premiums are due by the 15th of each month. Please remember these important deadlines! If you don t renew your coverage in time, it will end and you will not be eligible to re-enroll. Your dependents may enroll in Extended Coverage only if they were enrolled in family coverage during your last semester. You may add newly acquired dependents to your coverage as outlined on page 2. If adding a new dependent changes your coverage option and premium, the additional premium for the month in which the dependent became eligible must be included with the enrollment form within 31 days after you have received notice of the billing. If you are enrolled in Extended Coverage, you may receive your medical care from any qualified, appropriately licensed medical provider. However, it will be to your advantage to use providers who are part of Deseret Mutual s national Preferred Provider Network whenever possible. For more information about the Preferred Provider Network, see page 19. Extended Coverage plans are not eligible for Catastrophe Protection (see page 21). Coverage Periods You are covered while you are traveling to school and during on-campus activities before the first day of classes. This coverage is effective for up to seven days before you are due to report for classes or orientation. You have 60 days to enroll new family members acquired through marriage, birth, or adoption. Coverage for a new spouse or stepchildren will begin the first month following your date of marriage. Newborns or newborn adoptive children have coverage on their date of birth; adoptive children older than 60 days will have coverage effective on their date of placement with you. After adding a dependent due to an adoption, you have 31 days to pay any applicable premiums. When does coverage begin? For You and Current Dependents For a New Dependent Regular On-Campus or Awayfrom-Campus Coverage Extended Coverage First day of classes for new semester/block 12:01 a.m. on the day after your Regular On-Campus or Away-from-Campus coverage ends 12:01 a.m. on the date of the qualifying event 12:01 a.m. on the date of the qualifying event When does coverage end? Regular On-Campus or Awayfrom-Campus Coverage Extended Coverage After You Graduate, Lose Continuing Student Status, or Gain Other Coverage Last day before the next semester/block begins After Your Dependent Loses Eligibility Last day before the beginning of the semester following the semester in which the dependent becomes ineligible 12:01 a.m. on the first day of the month after the last month for which premiums have been paid BYU-Idaho Student Health Plan 5

15 After your coverage ends, you may request a Certificate of Creditable Coverage by calling Deseret Mutual. This is a document certifying the length of time you were covered by the Student Health Plan. When you enroll in another health plan, this certificate may help reduce the length of time that pre-existing conditions can be excluded from coverage. Coverage at Other Church Universities If you receive services at the SHC of another Church university, you will be covered as if you had received services at the BYU-Idaho SHC. You must pay the SHC copayment at the time of service. You don t need preauthorization. Premiums Premiums are due at the same time as tuition for each semester or block. For the exact dates that premiums are due, see the dates on page 26. If you change enrollment midyear, your premium (or additional premium, if necessary) will be due immediately when you enroll for the semester/block in which the change becomes effective. Single Student Only Single Student Plus Dependent(s) Married Student Only Married Student Plus Dependent(s) Regular On-Campus & Away-from-Campus Coverage Semester $ 270 Block $ 135 Summer Session $ 90 Semester $ 757 Block $ 379 Summer Session $ 253 Semester $ 318 Block $ 159 Summer Session $ 106 Semester $ 1,085 Block $ 543 Summer Session $ 362 Extended Coverage $ 650 per month $ 991 per month $ 650 per month $ 991 per month How the Plan Works Overview You should receive or coordinate all your medical care at the SHC (see page 8). When you receive services at the SHC, you pay an up front office visit fee of $10. If the SHC cannot treat you, you will be referred to a medical provider in the community. After you pay your copayment, the amount covered by the plan is your plan benefit (for example, 80%). The amount you pay (the remaining 20%) is your coinsurance. If you receive authorized services outside of the SHC, you pay an up front copayment to the medical provider. A copayment is a fixed dollar amount (usually $25) that you owe at the time services are received. For married student and family plans, plan benefits will not be paid for services received outside of the SHC until you meet your annual deductible of $750 per person (see page 8). Also, non-student spouses must meet a $4,750 deductible for maternity expenses. This means that non-student spouses need to pay the first $4,750 of the cost for their prenatal care and the delivery of the baby. Regular plan benefits and coinsurance apply to eligible expenses over $4,750. For more information, see page 8. 6 BYU-Idaho Student Health Plan

16 If you receive services outside of the SHC, you or your medical provider must submit an itemized bill to Deseret Mutual (see page 20). Deseret Mutual will process your claim, send a check for the plan benefit to the medical provider, and send you an explanation of benefits statement. This statement will itemize the charges, your deductible (if applicable), your copayment, the plan benefit, and your coinsurance. You must pay your copayment (if you haven t already done so) and your coinsurance to the medical provider. In some cases, the medical provider will bill more than Deseret Mutual s maximum allowable limit for the services you received (see page 36). If so, your explanation of benefits statement will also itemize how much of the bill is over the maximum allowable limit. If you receive your care from one of Deseret Mutual s contracted providers, you don t have to pay any amount over the maximum allowable limit. When health-care providers contract with Deseret Mutual, they agree not to bill you for more than the maximum allowable (for information about contracted providers, see page 19) If you receive your care from a provider who is not contracted with Deseret Mutual, you are responsible to pay any charges over the maximum allowable limit You are also responsible to pay your medical provider for any services that aren t covered by the plan. For more definitions of insurance terms used in this handbook, see page 35. Insurance Identification Card During the first semester that you enroll in the Student Health Plan, you will receive an insurance identification card. This card will be mailed to the address that BYU-Idaho submits to Deseret Mutual. You may request another card from Deseret Mutual by calling Copayments and Office Visit Fees You should receive or coordinate all your medical care at the SHC (see page 8). If the SHC cannot treat you, you will be referred to a medical provider in the community. Your office visit fees and copayments are as follows: Services at the SHC Services Outside of the SHC Physician Services, Outpatient Care, and Urgent Care: $25 copayment Physician Services: $10 office visit fee Hospital Emergency Room: $50 copayment Hospital Admission: $300 copayment Plan Benefits and Coinsurance After you have paid your office visit fee or copayment, benefits for the remainder of eligible expenses are: The plan pays: You pay: Services at the SHC 80% for lab and X-ray 20% for lab and X-ray Services Outside of the SHC Contracted providers: 80% Non-contracted providers: 50% Contracted providers: 20% Non-contracted providers: 50% BYU-Idaho Student Health Plan 7

17 Maximum Plan Benefit The maximum benefit is $250,000 per person per academic year. For information about Catastrophe Protection, please see page 21. Deductibles For married student and family plans, there is a $750 annual deductible per person (up to $1,500 per family) for services received outside of the SHC. This means that every plan year you must pay the first $750 of eligible medical expenses before you begin to receive plan benefits. Remember to send your claims to Deseret Mutual so that your deductible amounts can be tracked. This deductible does not apply to services provided by the SHC. For non-student spouses, there is a $4,750 deductible for maternity expenses in addition to the applicable copayments (see page 7). The plan year for all deductibles runs from September 1 to August 31. Preauthorization For services from a provider outside of the SHC, you must receive a referral from the SHC (not required for Awayfrom-Campus and Extended coverages). You must also receive preauthorization from Deseret Mutual before you receive the medical care. If you are referred by an SHC physician, this preauthorization will occur automatically. If your referred provider recommends care that is not specified in the referral from the SHC (such as additional office visits, tests at another facility, or consultation with another health-care provider), you must contact Deseret Mutual for preauthorization before you receive the additional care. Remember, care beyond the scope of the original SHC referral must also be authorized in advance by Deseret Mutual. Preauthorization requests will be responded to within two days. Even if you have preauthorization from Deseret Mutual to see an outside provider, that does not guarantee payment for any treatment you may receive. The guidelines, benefits, and exclusions of the plan will determine claims payment. Student Health Center The Student Health Center (SHC) provides or coordinates all medical care that is covered by the plan. If you need eligible services that the SHC can t provide, you ll be referred to contracted medical providers in the community. These providers have contracted with Deseret Mutual to offer care at a reduced cost to participants. The discounts will be reflected in the portion of charges that you are responsible to pay. The SHC is located on the first floor of the Student Health and Counseling Center. It is open to all students, spouses, and dependents who are covered by the Student Health Plan. Available Services The SHC has a staff of physicians and specialists who provide medical care in the following areas: Diagnostic X-ray, non-maternity ultrasound, Pediatrics and laboratory services Family medicine Pharmacy Internal medicine Premarital exams Orthopedics Routine physical exams 8 BYU-Idaho Student Health Plan

18 Payment for Services You are responsible for all costs incurred during each visit to the SHC except for the portion that is covered by the Student Health Plan. Your office visit fee is $10 for physician services. In addition to the office visit fee, SHC services are covered at normal plan benefits of 80%. That means you are responsible for paying the remaining 20% of charges in addition to your office visit fee. The cost for these services will be billed automatically to your personal student account. Operating Hours SHC hours are as follows (last appointment available one-half hour before closing): Mondays, Wednesdays, Thursdays, and Fridays 8 a.m. to 5 p.m. Tuesdays 8 a.m. to 2 p.m. and 3 p.m. to 5 p.m. Exceptions Closed holidays and selected days during break between fall and winter semester. Services Outside of the SHC The Student Health Plan covers hospitalization and many other specialized medical services that the SHC does not provide. If you need such services, you will be referred to a medical provider in the community. You must preauthorize all care you receive outside of the SHC, except for emergency and well-baby care. Also, for married student plans, benefits are paid after you meet the annual deductible ($750 per person up to $1,500 per family). Not all services are covered by the plan. To see which services are not covered, carefully read the exclusions beginning on page 22. The following are examples of services the plan covers outside of the SHC: Allergy Services Contracted provider: The plan pays 80% after your $25 copayment; you pay 20% Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% Ambulance (Land and Air) When medically necessary, the plan covers licensed ambulance services to the nearest medical facility equipped to furnish the appropriate care The plan pays 80% after your $25 copayment; you pay 20% Anesthesia The plan pays 80%; you pay 20% BYU-Idaho Student Health Plan 9

19 FOR MARRIED STUDENT PLANS, BENEFITS ARE PAID AFTER YOU MEET THE ANNUAL DEDUCTIBLE ($750 PER PERSON UP TO $1,500 PER FAMILY) Chemotherapy Contracted provider: The plan pays 80%; you pay 20% Non-contracted provider: The plan pays 50%; you pay 50% Dental Accident Benefit The plan pays 80% after your $25 copayment; you pay 20% The maximum benefit is $3,000 per academic year Benefits apply only to services made necessary as a direct result of a traumatic accidental injury (such as a car accident or a facial injury) that occurs while you are covered by the plan Benefits apply only to services received while you are insured by the plan and within two years of the accident Diabetes Education The plan pays 80% after your $25 copayment; you pay 20% The maximum benefit is $300 per academic year Diabetic Supplies The plan pays 80%; you pay 20% Dialysis Contracted provider: The plan pays 80%; you pay 20% Non-contracted provider: The plan pays 50%; you pay 50% Emergency Room The plan pays 80% after your $50 copayment; you pay 20% You do not need to authorize the initial visit, but you must preauthorize any follow-up care with Deseret Mutual If an urgent care facility is appropriate and available as a less expensive alternative, please see page 19 Eye Exams Contracted provider: The plan pays 80% after your $25 copayment; you pay 20% Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% One routine eye exam per person is eligible for benefits each academic year Eye exams for medical conditions, such as glaucoma, may be eligible for benefits more often. Additional benefits must be preauthorized 10 BYU-Idaho Student Health Plan

20 FOR MARRIED STUDENT PLANS, BENEFITS ARE PAID AFTER YOU MEET THE ANNUAL DEDUCTIBLE ($750 PER PERSON UP TO $1,500 PER FAMILY) Hearing Testing Contracted provider: The plan pays 80% after your $25 copayment; you pay 20% Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% Home Health Care Contracted provider: The plan pays 80% after your $25 copayment; you pay 20% Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% To be eligible for benefits, services must be performed by a licensed Registered Nurse or a Licensed Practical Nurse Custodial care, such as maintaining someone beyond the acute phase of injury or illness including room, meals, bathing, dressing, and home health aides, is not eligible for benefits You must preauthorize For more information, contact Deseret Mutual Inpatient Hospital Services Contracted provider: The plan pays 80%; you pay 20% Non-contracted provider: The plan pays 50%; you pay 50% You pay a $300 copayment per admission The plan covers any prescription drugs that are administered as part of an inpatient hospital service When semi-private rooms are available, the plan will not pay for private rooms Inpatient Physician Services Contracted provider: The plan pays 80%; you pay 20% Non-contracted provider: The plan pays 50%; you pay 50% Laboratory Services Contracted provider: The plan pays 80%; you pay 20% Non-contracted provider: The plan pays 50%; you pay 50% BYU-Idaho Student Health Plan 11

21 FOR MARRIED STUDENT PLANS, BENEFITS ARE PAID AFTER YOU MEET THE ANNUAL DEDUCTIBLE ($750 PER PERSON UP TO $1,500 PER FAMILY) Mammography Routine mammograms are eligible for benefits as follows: 1) One baseline mammogram for ages 35 through 39 2) One mammogram every two years for ages 40 through 49, or more frequently upon recommendation of a physician 3) One mammogram every year for ages 50 and older 4) One mammogram for any woman desiring a mammogram for medical necessity Maternity General Information Non-student spouses do not have coverage for normal maternity expenses. However, eligible expenses of more than $4,750 that are incurred as a direct result of complications of pregnancy will be covered, subject to normal plan provisions (see Maternity Non-Student Spouse on page 13) Contact the Student Health Center before you begin your prenatal care with an OB/GYN or Certified Nurse Midwife. To maximize your benefits, you should also contact Deseret Mutual to preauthorize care Maternity Students Hospital Services Contracted provider: The plan pays 80%; you pay 20% Non-contracted provider: The plan pays 50%; you pay 50% You pay a $300 copayment per admission (newborn infants are considered a separate admission from the mother and will also be subject to the copayment, if they are enrolled in the Student Health Plan) When you deliver at a contracted hospital, services are provided at discounted rates You must preauthorize medically necessary hospital stays of more than two days for a vaginal delivery or four days for a cesarean section delivery. If you do not preauthorize your extended hospital stay, additional days will be subject to medical review. For preauthorization, contact Deseret Mutual before your stay is extended. Preauthorization requests will be responded to within two days When semi-private rooms are available, the plan will not pay for private rooms Some maternity-related expenses, such as expenses for miscarriage or false labor, are not considered in the contracted hospital rates. In such cases, the hospital will charge its regular fees and the plan s regular benefits and hospital copayments will apply to these charges Physician / Certified Nurse-Midwife Services Contracted provider: The plan pays 80%; you pay 20% Non-contracted provider: The plan pays 50%; you pay 50% You pay a $25 copayment per visit (maximum total copayment of $250 for routine care) 12 BYU-Idaho Student Health Plan

22 FOR MARRIED STUDENT PLANS, BENEFITS ARE PAID AFTER YOU MEET THE ANNUAL DEDUCTIBLE ($750 PER PERSON UP TO $1,500 PER FAMILY) Maternity Students (continued) Physician / Certified Nurse-Midwife Services (continued) For students, regular plan benefits apply to all eligible maternity expenses. For information on non-student spouse benefits, see Maternity Non-Student Spouse below When you receive care from a contracted provider in Rexburg, services are provided at discounted rates The contracted rates are for prenatal care and delivery provided by one physician throughout the term of the pregnancy. If you are away from Rexburg for part of the pregnancy, or if your care must be provided by more than one doctor, be sure to get preauthorization Other physicians involved in the medical care for you and your baby, such as anesthesiologists or pediatricians, will bill you separately. Regular plan benefits and copayments will also apply to these charges Remember, you will receive separate bills for the newborn baby s medical care. If you want to add your newborn child to your Student Health Plan coverage and receive plan benefits for the baby s expenses, contact the insurance personnel at the Student Health Center within 60 days of the birth (see page 2) Maternity Non-student Spouse For non-student spouses, benefits are available only for eligible expenses of more than $4,750. The first $4,750 of expenses (as shown below) will be your responsibility. The $4,750 deductible also applies to expenses related to pre-term labor or miscarriage. Hospital Services You pay a $2,850 deductible and copayment for the mother s hospital bill. This includes the $300 hospital copayment You pay a $300 deductible and copayment for the baby s hospital bill, if they are enrolled in the Student Health Plan Contracted provider: The plan pays 80% of the remaining eligible expenses; you pay 20% Non-contracted provider: The plan pays 50% of the remaining eligible expenses; you pay 50% Physician / Certified Nurse-Midwife Services You pay a $1,900 deductible and copayment for the mother s physician bill for prenatal care and delivery. This includes the $250 maximum physician copayment Contracted provider: The plan pays 80% of the remaining eligible expenses; you pay 20% Non-contracted provider: The plan pays 50% of the remaining eligible expenses; you pay 50% BYU-Idaho Student Health Plan 13

23 FOR MARRIED STUDENT PLANS, BENEFITS ARE PAID AFTER YOU MEET THE ANNUAL DEDUCTIBLE ($750 PER PERSON UP TO $1,500 PER FAMILY) Medical Equipment (Durable) Durable medical equipment is a device that is durable, primarily serves a medical purpose, generally is not useful to people in the absence of illness, injury, or congenital defect, and is appropriate for use in the home. Please note, not all equipment that meets these requirements is eligible for benefits Contracted provider: The plan pays 80% after your $25 copayment; you pay 20% Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% To be eligible for benefits, you must have a prescription from your physician You must preauthorize certain medical equipment. For information about equipment requiring preauthorization, please see the table below. If you do not, the purchase or rental of the equipment will be reviewed retrospectively (after the fact) to determine if it is eligible for coverage Time limitations apply to replacing some equipment You are responsible for expenses associated with the maintenance and upkeep of your medical equipment In some instances, if you purchase the equipment after you rent it, the rental price may be applied to the purchase price Medical Equipment Must be preauthorized Bone growth stimulators Communication devices CPM machines Gait trainers Helmet therapy Hospital beds / mattresses Insulin pumps Intermittent limb compression devices Light boxes for dermatological problems Lymphopresses Oxygen concentrators Respirators / ventilators Scooters Standers Tens units / EMS units ThAIRpy vests Wheelchairs Does not need to be preauthorized Apnea monitors (newborns only) Bilirubin lights Blood pressure kits Breast prosthetics (external) Canes Commodes Crutches Enteral infusion pumps / Kangaroo feeding pumps Glucometers Hoyer lifts Nebulizers / Pulmoaides Orthopedic braces Overhead trapeze Oxygen Pacemakers Reflux boards Side rails for beds Transfer boards Walkers Is not eligible for benefits Air filtration systems Breast pumps Exercise equipment Eye glasses / contact lenses Hearing devices Humidifiers / dehumidifiers Interferential stimulators Knee braces used solely for sports Learning devices Lift chairs Modifications associated with: Activities of daily living Homes / structures Vehicles Spa memberships Thermal therapy devices (cold / hot) Whirlpools 14 BYU-Idaho Student Health Plan

24 FOR MARRIED STUDENT PLANS, BENEFITS ARE PAID AFTER YOU MEET THE ANNUAL DEDUCTIBLE ($750 PER PERSON UP TO $1,500 PER FAMILY) Medical Supplies Medical supplies are disposable, one-use-only medical items for immediate use. These include dressings and ace bandages Contracted provider: The plan pays 80%; you pay 20% Non-contracted provider: The plan pays 50%; you pay 50% To be eligible for benefits, you must have a prescription from your physician Mental Health Therapy Contracted provider: The plan pays 80% after your $25 copayment; you pay 20% Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% Residential treatment is not covered To be eligible for benefits, services must be provided by a physician, psychologist, clinical social worker, or advanced practice registered nurse You must preauthorize all mental health services outside the SHC Office Visits Contracted provider: The plan pays 80% after your $25 copayment; you pay 20% Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% You do not need to preauthorize well-care visits for children Students, spouses, and other dependents must preauthorize unless you are enrolled in the Away-from-Campus or Extended Coverage option (see page 4) Pain Clinics Contracted provider: The plan pays 80%; you pay 20% Non-contracted provider: The plan pays 50%; you pay 50% The benefit is for either inpatient or outpatient care When semi-private rooms are available, the plan does not pay for private rooms Outpatient services have a five visit or $1,500 benefit limit. Each visit is subject to the contracted and noncontracted rates after your $25 copayment BYU-Idaho Student Health Plan 15

25 FOR MARRIED STUDENT PLANS, BENEFITS ARE PAID AFTER YOU MEET THE ANNUAL DEDUCTIBLE ($750 PER PERSON UP TO $1,500 PER FAMILY) Physical Therapy Outpatient Contracted provider: The plan pays 80% after your $25 copayment; you pay 20% Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% The plan covers up to 20 visits per person per academic year Inpatient visits do not count toward your annual outpatient visit limit You may receive preauthorization for a series of visits at one time Prescription Drug At SHC Pharmacy & at Network Retail Pharmacies High-cost and specialty drugs are excluded by the plan Covered Brand and Generic Drugs: The plan pays 80%; you pay 20% Non-covered Brand and Generic Drugs: You pay 100% Benefits are limited to a 30-day supply Prescription drugs are not included in Catastrophe Protection (see page 21). If you qualify for Catastrophe Protection, standard prescription benefits will remain in effect For more information about covered drugs and retail pharmacy locations, call Deseret Mutual at in the Salt Lake City area or toll free at Or call VRx at or Preventive Services Contracted provider: The plan pays 100%; no copayment applies Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% To be covered by the Student Health Plan, you must buy over-the-counter preventive medicines at a network pharmacy See the table on page 17 for a list of covered services and general information For more information about mandated preventive service coverage, call Deseret Mutual at in the Salt Lake City area or toll free at Prosthetics This benefit includes prosthetics such as artificial arms or legs Contracted provider: The plan pays 80% after your $25 copayment; you pay 20% Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% To be eligible for benefits, you must have a prescription from your physician 16 BYU-Idaho Student Health Plan

26 FOR MARRIED STUDENT PLANS, BENEFITS ARE PAID AFTER YOU MEET THE ANNUAL DEDUCTIBLE ($750 PER PERSON UP TO $1,500 PER FAMILY) Services for Adults (Ages 19+) Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked Alcohol Misuse screening and counseling Aspirin use for men and women of certain ages Blood Pressure screening for all adults Cholesterol screening for adults of certain ages or at higher risk Colorectal Cancer screening for adults over 50 Depression screening for adults Type 2 Diabetes screening for adults with high blood pressure Diet counseling for adults at higher risk for chronic disease HIV screening for all adults at higher risk Immunization vaccines for adults doses, recommended ages, and recommended populations vary Obesity screening and counseling for all adults Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk Tobacco Use screening for all adults and cessation interventions for tobacco users Syphilis screening for all adults at higher risk Services for Children & Adolescents (Ages 0-18) Alcohol and Drug Use assessments for adolescents Autism screening for children at 18 and 24 months Behavioral assessments for children of all ages Blood Pressure screening for children Cervical Dysplasia screening for sexually active females Congenital Hypothyroidism screening for newborns Depression screening for adolescents Developmental screening for children under age 3, and surveillance throughout childhood Dyslipidemia screening for children at higher risk of lipid disorders Fluoride Chemoprevention supplements for children without fluoride in their water source Gonorrhea preventive medication for the eyes of all newborns Hearing screening for all newborns Height, Weight and Body Mass Index measurements for children Hematocrit or Hemoglobin screening for children Hemoglobinopathies or sickle cell screening for newborns HIV screening for adolescents at higher risk Immunization vaccines for children from birth to age 18 doses, recommended ages, and recommended populations vary Iron supplements for children ages 6 to 12 months at risk for anemia Lead screening for children at risk of exposure Medical History for all children throughout development Obesity screening and counseling Oral Health risk assessment for young children Phenylketonuria (PKU) screening for this genetic disorder in newborns Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk Tuberculin testing for children at higher risk of tuberculosis Vision screening for all children Services for Women Anemia screening on a routine basis for pregnant women Bacteriuria urinary tract or other infection screening for pregnant women BRCA counseling about genetic testing for women at higher risk Breast Cancer Mammography screenings every 1 to 2 years for women over 40 Breast Cancer Chemoprevention counseling for women at higher risk Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women Cervical Cancer screening for sexually active women Chlamydia Infection screening for younger women and other women at higher risk Domestic and interpersonal violence screening and counseling for all women Folic Acid supplements for women who may become pregnant Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes Gonorrhea screening for all women at higher risk Hepatitis B screening for pregnant women at their first prenatal visit Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older Osteoporosis screening for women over age 60 depending on risk factors Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users Sexually Transmitted Infections (STI) counseling for sexually active women Syphilis screening for all pregnant women or other women at increased risk Well-woman visits to obtain recommended preventive services for women under BYU-Idaho Student Health Plan 17

27 FOR MARRIED STUDENT PLANS, BENEFITS ARE PAID AFTER YOU MEET THE ANNUAL DEDUCTIBLE ($750 PER PERSON UP TO $1,500 PER FAMILY) Radiation Therapy Contracted provider: The plan pays 80%; you pay 20% Non-contracted provider: The plan pays 50%; you pay 50% Radiology Services (X-rays, CT Scans, MRIs, etc.) The plan pays 80% after your $25 copayment; you pay 20% Routine mammograms are eligible for benefits as follows: 1) One baseline mammogram for ages 35 through 39 2) One mammogram every two years for ages 40 through 49, or more frequently upon recommendation of a physician 3) One mammogram every year for ages 50 and older 4) One mammogram for any woman desiring a mammogram for medical necessity Substance Abuse Contracted provider: The plan pays 80% after your $25 copayment (for outpatient services); you pay 20% Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% Residential treatment is not covered You must preauthorize Surgery Inpatient Hospital Services Contracted provider: The plan pays 80% after your $25 copayment; you pay 20% Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% Surgery Outpatient Hospital Services Contracted provider: The plan pays 80% after your $200 copayment; you pay 20% Non-contracted provider: The plan pays 50% after your $200 copayment; you pay 50% Surgery Physician Services Contracted provider: The plan pays 80% after your $25 copayment; you pay 20% Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% 18 BYU-Idaho Student Health Plan

28 FOR MARRIED STUDENT PLANS, BENEFITS ARE PAID AFTER YOU MEET THE ANNUAL DEDUCTIBLE ($750 PER PERSON UP TO $1,500 PER FAMILY) Urgent Care Facility The plan pays 80% after your $25 copayment; you pay 20% You do not need to authorize the initial visit, but you must preauthorize any follow-up care with Deseret Mutual For more information about what to do in an emergency, see page 20 Well-baby Care Contracted provider: The plan pays 80% after your $25 copayment; you pay 20% Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% Immunizations are not eligible for benefits You don t need to preauthorize well-baby care Women s Health & Cancer Act A law called the Women s Health and Cancer Rights Act of 1998 requires group health plans that cover mastectomies to cover breast reconstruction and prostheses. We re proud that Deseret Mutual s health plans already comply with this law as shown below: Contracted provider: The plan pays 80% after your $25 copayment; you pay 20% Non-contracted provider: The plan pays 50% after your $25 copayment; you pay 50% Deseret Mutual s Preferred Provider Network If you are away from the Rexburg area while you re enrolled in the Student Health Plan, you may obtain care from any qualified, appropriately licensed medical provider. However, it s to your advantage to make sure the physicians and hospitals providing your care are contracted as part of Deseret Mutual s Preferred Provider Network. Your benefits will be higher and the providers will not bill you for fees that exceed Deseret Mutual s maximum allowable amounts. This network extends throughout most areas of the United States, and includes physicians and hospitals that provide quality care at substantially discounted rates. For information about providers in your area, please see the following networks. Find a Contracted Medical Provider: Southeast Idaho & Utah: Deseret Mutual Contracted Providers or (click on Find a Provider ) Hawaii: MDX Contracted Providers Other Areas (for services through December 31, 2012): Washington State: First Choice Health Network, Inc or All other states: First Health National PPO or Other Areas (for services on or after January 1, 2013): All other states: UnitedHealthcare Options PPO BYU-Idaho Student Health Plan 19

29 Remember, eligible expenses for services from contracted providers are covered at 80% while eligible expenses from non-contracted providers are covered at 50%. Emergencies In an emergency, you should always get the appropriate care immediately. For non-life threatening situations, you ll pay $10 at the SHC plus 20% coinsurance. At an urgent care facility, you ll pay a $25 copayment plus 20% coinsurance. At a hospital emergency room, you ll pay a $50 copayment plus 20% coinsurance. Life-threatening Emergencies If you are faced with a life-threatening emergency, you should seek immediate medical treatment from a qualified, accessible provider. Plan benefits for treatment outside of the SHC will apply. Life-threatening emergencies are those in connection with a sudden and unexpected onset of a condition requiring immediate medical or surgical care to safeguard the patient s life. This includes heart attack, severe bleeding, loss of consciousness, convulsions, or temperature of more than 104 Fahrenheit. Other Medical Emergencies Other medical emergencies are those that are not life threatening, but the onset of symptoms is so sudden and severe that immediate medical or surgical treatment is required to prevent serious impairment of bodily functions. In the case of an emergency that is not life threatening while the SHC is open, you should obtain care from the SHC. If any emergency occurs when the SHC is closed, you should go to the Madison Memorial Hospital emergency room or the urgent care facility listed below. Plan benefits for treatment outside of the SHC will apply. Community Care Center 72 East Main Street Rexburg, Idaho If you receive services in an emergency room and you are subsequently admitted to the hospital, you must call Deseret Mutual to preauthorize the admission within two business days. If you receive emergency care in a physician s office after business hours, you must also call Deseret Mutual for preauthorization. Follow-up to Emergency Care For all emergencies, contact Deseret Mutual at before you receive any follow-up care. If you need to receive follow-up care outside of the SHC, you must preauthorize with Deseret Mutual before you receive the care. Submitting Claims for Payment To receive plan benefits for services provided outside of the SHC, submit an itemized bill and claim form (available from Deseret Mutual), along with the preauthorization, to: Student Health Plans Deseret Mutual Benefit Administrators P.O. Box Salt Lake City, Utah Beginning January 1, 2013: If you receive services outside of Southeast Idaho, Utah, or Hawaii your provider should send claims directly to UnitedHealthcare. The address is on the back of your insurance ID card. To be eligible for coverage, claims must be submitted within 12 months of the date of service. You don t need to submit claims for services received at the SHC. 20 BYU-Idaho Student Health Plan

30 Claims Payment Timelines We ll pay or deny electronic claims within 30 days of receiving them. We ll pay or deny paper claims within 45 days of receiving them. If we deny a claim or need more information, we ll contact the provider or facility within 30 days of receiving an electronic claim, or 45 days of receiving of a paper claim. If we deny a claim because we need more information, and the provider submits the information within 30 days, then we ll reprocess the claim within 30 days of receiving the information. Catastrophe Protection If your share of eligible expense reaches a certain limit per academic year (your annual maximum coinsurance), your benefits for the remainder of the academic year are paid according to the catastrophe protection of the plan, up to your $250,000 annual plan maximum benefit. For individuals (students and/or dependents) covered by the BYU-Idaho Student Health Plan, after your share of eligible expenses reaches $5,000, benefits increase to 100% for eligible charges (up to $250,000), based on Deseret Mutual s maximum allowable limits. However, catastrophe protection does not apply to all benefits. You will continue to be responsible for copayments and coinsurance on the following benefits : Hospital emergency room Mental health outpatient care Office visits Therapy (such as physical therapy) Urgent care facility Also, expenses for the following services do not apply to your annual maximum coinsurance amount and are not covered by the catastrophe protection of the plan: Infusion therapy drugs purchased through you physician s office Prescription drugs Finally, the following expenses do not apply to your annual maximum coinsurance amount and are not covered by the catastrophe protection of the plan: Amounts that exceed the maximum allowable limits Annual deductibles for married students Ineligible amounts Non-student spouse maternity deductible Premium payments Any other expenses not covered by the plan Repatriation of Remains If a covered accident or illness causes the death of an insured student while he or she is in a foreign country (that is, the student is not a citizen of the country), the plan will pay expenses for returning the body to the country of citizenship up to a maximum benefit of $7,500. To be eligible for coverage, expenses must be approved in advance. For more information, call Deseret Mutual at BYU-Idaho Student Health Plan 21

31 Exclusions Services that do not meet the definitions of eligible, as previously defined, are not eligible for coverage by any coverage option. In addition, the following services and their associated costs are excluded from coverage: Alternative Care 1.1 Holistic, homeopathic, ecological, or environmental treatment 1.2 Acupuncture 1.3 Vertebral column rehabilitation (chiropractic care) or massage therapy Congenital Anomalies 2.1 Care, treatment, or operations provided outside of the SHC in connection with congenital anomalies when such services are performed to restore normal body form or appearance, the conditions are not immediately life threatening, and/or the timing is subject to the choice or decision of the patient and physician. This exclusion does not apply to care, treatment, or operations to treat congenital anomalies in individuals up to (but not including) 19 years of age Convenience / Cosmetic Services 3.1 Care, treatment, supplies, or other services incurred primarily for convenience, contentment, or other nontherapeutic purposes, or are not clearly a medical necessity 3.2 Care, treatment, or operations that are performed primarily for cosmetic purposes (non-suspicious mole removal, normal or abnormal hair loss, etc.), except for expenses incurred as a result of injury suffered while covered by the plan 3.3 Care, treatment, diagnostic procedures, or other expenses for an abdominoplasty, breast reduction, lipectomy, panniculectomy, skin furrow removal, or diastasis rectus repair Custodial Care 4.1 Custodial care, education, training, or rest cures 4.2 Inpatient hospitalization or residential treatment for the primary purpose of providing shelter and/or safe residence Dental Care 5.1 Dental treatment, except that made necessary by accidental injury to sound natural teeth, as provided for by the plan Diagnostic & Experimental Services 6.1 Care, treatment, diagnostic procedures, or operations that are: Considered medical research Investigative/experimental technology Not recognized by the U.S. medical profession as usual and/or common Determined by Deseret Mutual not to be usual and/or common medical practice Illegal That a physician might prescribe, order, recommend, or approve services or medical equipment does not, of itself, make it an allowable expense, even though it is not specifically listed as an exclusion. Investigative/experimental technology means treatment, procedure, facility, equipment, drug, device, or supply that does not, as determined by Deseret Mutual on a case-by-case basis, meet all of the following criteria: The technology must have final approval from all appropriate governmental regulatory bodies, if applicable The technology must be available in significant number outside the clinical trial or research setting The available research about the technology must be substantial. For plan purposes, substantial means sufficient to allow Deseret Mutual to conclude the technology is: both medically necessary and appropriate for the covered person s treatment safe and efficacious more likely than not will be beneficial to the covered person s health Procedures, care, treatment, or operations falling in the categories described herein continue to be excluded until actual experience clearly defines them as non-experimental and they are specifically included in the medical policy by Deseret Mutual 22 BYU-Idaho Student Health Plan

32 Exclusions (continued) Educational Programs 7.1 Educational programs (PMS clinics, etc.) except diabetes education Fertility / Family Planning / Home Delivery 8.1 Reproductive organ prostheses 8.2 Care, treatment, or operations provided in connection with sexual dysfunction 8.3 Care, treatment, or operations in connection with infertility 8.4 Care, treatment, or operations in relation to in vitro fertilization 8.5 Elective abortions, meaning an abortion for any reason other than to preserve the life of the female upon whom the abortion is performed 8.6 Family planning, including contraception, birth control devices, surgery, and/or drugs 8.7 Planned home delivery for childbirth and all associated costs 8.8 Services related to evaluation and treatment of cause(s) of multiple miscarriages (miscarriage itself is covered) 8.9 All services and expenses related to a surrogate pregnancy or other pregnancy resulting in the adoption of a child (including care, treatment, delivery, diagnostic procedures, or operations, as well as maternity care for the surrogate mother and prenatal/postnatal care for the newborn child) are excluded. All services and expenses for complications related to a surrogate pregnancy or other pregnancy resulting in the adoption of a child are also excluded Government / War 9.1 Services furnished by a hospital or facility owned or operated by the United States Government or any agency thereof; any charges for services, treatments, or supplies furnished by or for the United States Government or any agency thereof 9.2 Services covered or that could have been covered by any governmental plan had the participant complied with the requirements of the plan, including but not limited to Medicare or Medicaid 9.3 Services required as a result of war or act of war or service in the military forces of any country at war, declared or undeclared. War includes hostilities conducted by force or arms by one country against another country, or between countries or factions within a country, either with or without a formal declaration of war Hearing 10.1 The purchase or fitting of hearing devices Legal Exclusions 11.1 Accidents sustained as a result of play, practice, or participation in professional activities (including intercollegiate sports and vehicular contests) 11.2 Injury arising from participation in or attempt at committing an assault or felony, participation in illegal acts of violence, or services provided as a result of a court order or for other legal proceedings 11.3 Services that the individual is not, in the absence of this coverage, legally obligated to pay 11.5 Services or materials covered or that could have been covered by insurance required or provided by any statute, including but not limited to no-fault insurance, except as provided at the SHC 11.6 Conditions resulting from catastrophic events defined as an earthquake, fire, any other accidental occurrence or series of one event, or a group of related events within seven days or less resulting in the death or serious injury of 20 or more covered students 11.7 Complications resulting from excluded services 11.8 Services not specified as covered 11.9 Care, treatment, or operations incurred after coverage ends Medical Equipment 12.1 Breast pumps, knee braces used solely for sports, and learning devices 12.2 Multipurpose equipment or facilities, such as those listed in the Medical Equipment chart on page Modifications to homes, other structures, or motor vehicles to accommodate activities of daily living BYU-Idaho Student Health Plan 23

33 Exclusions (continued) Medical Necessity 13.1 Care, treatment, or operations that are not clearly a medical necessity. Medically Necessary: Services or supplies that are proper and needed for a legitimate diagnosis or a cost-efficient treatment of your medical condition; are used for the diagnosis, direct care, and treatment of your medical condition; meet the standards of good medical practice in the local community; and are not mainly for the convenience of you or your doctor 13.2 Treatment or removal of warts, toenails, corns, calluses, or bunions outside of the SHC 13.3 Care, treatment, or operations for bunions 13.4 Cardiopulmonary fitness training or conditioning (meaning reimbursement for gym, health, or fitness club memberships or fees), either as a preventive or therapeutic measure Mental Health / Counseling / Chemical Dependency 14.1 Marriage and family counseling provided outside the SHC 14.2 Care or treatment provided outside the SHC in connection with anorexia, bulimia, or other eating disorders 14.3 Care or treatment for mental health, counseling, or chemical dependency rendered in a residential treatment center 14.4 Evaluation and/or treatment for learning disabilities and/or physical or mental developmental delay, including pervasive developmental disorders, and/or cognitive dysfunctions Miscellaneous 15.1 Physical exams for the purpose of obtaining insurance, employment, or government licensing 15.2 Care, treatment, diagnostic procedures, equipment, or any other services for sleep disorders, chronic fatigue, or fibromyalgia 15.3 Deseret Mutual excludes sex change operations and all associated procedures and services (medical, psychological, pharmaceutical, surgical, etc.) from benefits in all medical plans 15.4 Care, treatment, diagnostic procedures, or other expenses when it has been determined by an attending physician that brain death has occurred 15.5 Services of any practitioner of the healing arts who ordinarily resides in the same household with you or your dependents, or has legal responsibility for financial support and maintenance of you or your dependents Obesity 16.1 Care, treatment, or operations in connection with obesity or weight loss (including gastric bypass surgery) Other Insurance / Workers Compensation 17.1 Services covered or that could have been covered by applicable workers compensation statutes 17.2 Services that a third party, the liability insurance of a third party, or the uninsured motorist insurance pays or is obligated to pay Plan Coverage 18.1 Services provided before coverage begins, including hospital stays in progress on the effective date of coverage and services after coverage ends Prescription Drugs, Specialty Pharmacy Medications, Formulas, & Supplements 19.1 Preventive medicine or vaccines, including immunizations 19.2 Special formulas, food supplements, or special diets 19.3 Excluded medications such as contraceptive pills for birth control, dietary or nutritional products and/or supplements (including special diets for medical problems), herbal remedies, homeopathic treatments, products used to stimulate hair growth, medications used for sexual dysfunction, medications whose use is for cosmetic purposes, over-the-counter products, vitamins, weight reduction aids, and non-federal legend status drugs Routine Services 20.1 Physical examination for the purpose of obtaining insurance, employment, government licensing, or as needed for volunteer work unless otherwise provided for by the terms of the plan 24 BYU-Idaho Student Health Plan

34 Exclusions (continued) Speech Therapy 21.1 Speech therapy and evaluation TMJ 22.1 Services and materials in connection with disturbances of the temporomandibular joint (TMJ) 22.2 Jaw surgery (osteotomy) Testing 23.1 Diagnostic services that are not related to an injury or illness, unless otherwise provided for by the plan 23.2 Some allergy tests including but not limited to ALCAT testing / food intolerance testing, cytotoxic food testing (Bryan s Test, ACT), Conjunctival Challenge Test (electro-acupuncture), Leukocyte Histamine Release Test (LHRT), Passive Transfer (PX) or Prausnitz-Kustner (PK) Test, Provocative Nasal Test, provocative food and chemical testing (intradermal, subcutaneous, or sublingual), Rebuck Skin Window Test, Rinkel Test, and skin endpoint titration Transplants 24.1 Medications, care, treatment, diagnostic procedures, or operations in relation to transplants (donor or artificial) Vision 25.1 Eyeglasses and contact lenses or the replacement or prescription thereof 25.2 Care, treatment, diagnostic procedures, or any other expenses for elective surgeries to correct vision including radial keratotomy or LASIK surgery, unless otherwise provided for by the terms of the plan Subrogation If you have an injury that is the liability of another party and you have the right to recover damages, Deseret Mutual has the right of subrogation and will require reimbursement for any amount it has paid when damages are recovered from the third party. Deseret Mutual will be reimbursed: First From any recovery from a claim against a third party, the third party s liability insurance carrier, or your uninsured and/or underinsured motorist insurance carrier Whether the recovery is obtained by settlement, judgment, or from any other source Regardless of how the settlement is allocated by the third party or insurance carrier Your acceptance of Deseret Mutual benefits for the injury constitutes subrogation. You must provide any information Deseret Mutual requests for subrogation purposes. If you fail to do so, you will be responsible for reimbursing all the costs and expenses paid by Deseret Mutual for the injury. Notification of Benefit Changes Deseret Mutual reserves the right to amend or terminate the plan at any time. If benefits change, we will notify you at least 30 days before the effective date of change. For the most up-to-date listing of plan benefits and exclusions, refer to the Student Health Plan handbook website at According to Idaho insurance law, if BYU-Idaho should terminate the Student Health Plan contract, any unused portion of the premium returns to BYU-Idaho as the policy holder BYU-Idaho Student Health Plan 25

35 Fraud Policy Statement It is unlawful to knowingly provide false, incomplete, or misleading facts or information with the intent of defrauding Deseret Mutual. An application for insurance or statement of claim containing any materially false or misleading information may lead to reduction, denial, or termination of benefits or coverage under the policy and recovery of any amounts Deseret Mutual may have paid. Non-compliance with a contract prepared by Deseret Mutual addressing abuse of health-care benefits or systems may also lead to reduction, denial, or termination of benefits or coverage under the policy and recovery of any amounts Deseret Mutual may have paid. Legal Notice This handbook provides you with an explanation of your benefits under the BYU-Idaho Student Health Plan and constitutes a legal contract between you and Deseret Mutual. Important Dates Fall Semester 2012 Sep.10 Classes start and coverage begins Sep.17 Fall open enrollment ends; last day to waive coverage Jan. 6 Fall semester coverage ends Fall Second Block 2012 Oct.25 Classes start and coverage begins Nov. 1 Second block insurance premium payment deadline Jan. 6 Coverage ends Winter Semester 2013 Jan. 7 Classes start and coverage begins Jan. 14 Winter open enrollment ends; last day to waive coverage Apr.21 Winter semester coverage ends Winter Second Block 2013 Feb. 25 Classes start and coverage begins Mar. 4 Second block insurance premium payment deadline Apr.21 Coverage ends Spring Semester 2013 Apr.22 Classes start and coverage begins Apr.29 Spring open enrollment ends; last day to waive coverage Sep.15 Spring semester coverage ends Spring Second Block 2013 Jun. 6 Classes start and coverage begins Jun. 13 Second block insurance premium payment deadline Sep.15 Coverage ends Summer Session 2013 Jul. 29 Classes start and coverage begins Aug. 5 Second block insurance premium payment deadline Sep.15 Coverage ends 26 BYU-Idaho Student Health Plan

36 Internal Claims Procedures This internal claims procedure applies to each health and welfare benefit offered under the BYU-Idaho Student Health Plan. Claims for benefits and subsequent appeals under the plan will be filed in accordance with the procedures set forth in this section of the plan handbook and any subsequent amendments, schedules, or attachments thereto. Initial Claim You may initiate a claim for benefits by contacting Deseret Mutual. Deseret Mutual will inform you of the information required to complete the claim, that may vary depending on the type of benefit and may include: A completed electronic or paper claim form, in a format provided by Deseret Mutual Reasonable documentation from the Student Health Center physician or other provider or official describing and/or verifying the injury, illness, or other condition or event giving rise to your claim Copies of bills for services rendered, including your name; the provider s name, address, and telephone number; the diagnosis; the type(s) of service rendered, with diagnosis and/or procedure codes; the date(s) of service; and the charges Claims must be filed with Deseret Mutual within 60 days of the date charges for the services were incurred. Benefits are based on the plan s provisions at the time the charges were incurred. Claims filed later than that date may be declined or reduced unless: (a) it is not reasonably possible to submit the claim in that time; and (b) the claim is submitted within one year from the date incurred. Deseret Mutual will determine if enough information has been submitted to enable proper consideration of the claim. If not, more information may be requested from you. The Student Health Plan reserves the right to require you to seek a second medical opinion. A request for plan benefits will be considered a claim for Plan benefits, and it will be subject to a full and fair review. Timing of Initial Decision and Calculating Time Periods The period within which a benefit determination is required to be made will begin at the time a claim is filed in accordance with the procedures set forth under Initial Claim above, without regard to whether all of the information necessary to make a benefit determination accompanies the filing. If a period is extended because you don t submit information necessary to decide a claim, the period for making the benefit determination will be tolled from the date the notification of the extension is sent to you until the date you respond to the request for additional information. Claims Under the Student Health Plan The following claims procedure will apply specifically to claims made for benefits under the plan. Urgent Claims That Require Immediate Action Urgent care claims are those claims that require notification or approval before receiving medical care, where a delay in treatment could seriously jeopardize your life or health or the ability to regain maximum function or, in the opinion of a doctor with knowledge of your health condition, could cause severe pain. In these situations: You will receive notice of the benefit determination (whether or not adverse) in writing or electronically as soon as possible taking into account the medical exigencies, but not later than 72 hours after Deseret Mutual receives all necessary information. Notice of denial may be oral with a written or electronic confirmation to follow within three days BYU-Idaho Student Health Plan 27

37 If you filed an urgent care claim improperly, Deseret Mutual will notify you of the improper filing and how to correct it within 24 hours after the urgent care claim was received. If additional information is needed to process the claim, Deseret Mutual will notify you of the information needed within 24 hours after the claim was received. You then have 48 hours to provide the requested information. In determining whether a claim is urgent, Deseret Mutual will defer to your attending provider s determination. You will be notified of a determination no later than 48 hours after: Deseret Mutual s receives the requested information; or The end of the 48-hour period within which you were to provide the additional information, if the information is not received within that time. Pre-Service Claims Pre-service claims require notification or approval before receiving health care. If your claim is a pre-service claim, and is submitted properly with all needed information, you will receive written notice of the claim decision (whether or not adverse) from Deseret Mutual within a reasonable period, but not later than 15 days following the claim is received. If you filed a pre-service claim improperly, Deseret Mutual will notify you of the improper filing and how to correct it within five days after the pre-service claim is received. Deseret Mutual will notify you of its determination within 15 days after the claim is received, unless Deseret Mutual determines, in its discretion, that special circumstances require an extension of time for processing the claim. If an extension is required, a written or electronic extension notice indicating the special circumstances requiring the extension and the date Deseret Mutual expects to render a decision will be furnished to you before the end of the initial 15-day period. If the extension is necessary because of your didn t provide missing information and you are notified of that fact, the extension will not exceed a period of 15 days beginning as of the earlier of (i) the date the missing information is received by Deseret Mutual, or (ii) the end of a 45-day period afforded to you to provide the missing information. If all of the needed information is received within the 45-day time frame, Deseret Mutual will notify you of the determination within 15 days after the information is received. If you don t provide the needed information within the 45-day period, your claim will be denied. If the extension is requested for reasons other than your failure to provide missing information, the extension will not exceed 15 days from the end of the initial 15 day period. Post-Service Claims Post-service claims are those claims that are filed for payment of benefits after health care has been received. If your post-service claim is denied, you will receive a written notice of the claim decision (whether or not adverse) from Deseret Mutual within a reasonable period, but not later than 30 days after the claim is received, as long as all required information was provided with the claim. Deseret Mutual will notify you of its determination within 30 days after the claim is received, unless Deseret Mutual determines, in its discretion, that special circumstances require an extension of time for processing the claim. If an extension is required, a written or electronic extension notice indicating the special circumstances requiring the extension and the date Deseret Mutual expects to render a decision will be furnished to you before the end of the initial 30-day period. If the extension is necessary because you didn t provide missing information and you are notified of that fact, the extension will not exceed a period of 15 days beginning as of the earlier of (i) the date the missing information is received by Deseret Mutual, or (ii) the end of a 45-day period afforded to you to provide the missing information. If all of the needed information is received within the 45-day time frame, Deseret Mutual will notify you of the determination within 15 days after the information is received. If you don t provide the needed information within the 45-day period, your claim will be denied. If the extension is requested for reasons other than your failure to provide missing information, the extension will not exceed 15 days from the end of the initial 30-day period. 28 BYU-Idaho Student Health Plan

38 Special Rules for Concurrent Decisions 1. Your request to extend previously approved course of treatment Urgent care: If an ongoing course of treatment was previously approved for a specific period or number of treatments, and a request to extend the treatment is an urgent care claim, the request will be decided by Deseret Mutual within 24 hours after the request is received, provided the request is made at least 24 hours before the end of the approved treatment. If the request for extended treatment is not made at least 24 hours before the end of the approved treatment, the request will be treated as an urgent care claim and decided according to the timeframes described on page 27. Non-urgent care: If an ongoing course of treatment was previously approved for a specific period or number of treatments, and a request to extend treatment is not an urgent care claim, the request will be considered a new claim and decided according to the post-service or pre-service timeframes described on page 28, whichever applies. 2. Plan reduces or terminates a previously approved course of treatment If an ongoing course of treatment was previously approved for a specific period or number of treatments, and the plan reduces or terminates such course of treatment (other than by plan amendment or termination) before the end of such period or number of treatments, the reduction or termination will be considered an adverse benefit determination (see below) and you will be notified of the reduction or termination (sufficiently in advance of the termination or reduction to appeal the decision and get a determination upon review of the decision) before the course of treatment is reduced or terminated. Notice of Initial Internal Adverse Benefit Determination If your claim is wholly or partially denied, or there occurs a rescission of coverage (within the meaning of Public Health Service Act, section 2712), Deseret Mutual will provide you with written notice of the initial adverse benefit determination. The notice will set forth the following information, in a manner calculated to be understood by you, the participant: (a) Specific reason or reasons for the initial internal adverse benefit determination (b) Specific reference to those plan provisions on which the initial internal adverse benefit determination is based (c) Description of any additional information or material necessary to perfect the claim and an explanation of why such material or information is necessary (d) Appropriate information as to the steps to be taken if you wish to submit the claim for review (e) In the case of an initial internal adverse benefit determination by the plan: If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the initial internal adverse benefit determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the initial adverse benefit determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to you upon request If the initial internal adverse benefit determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request (f) In the case of an initial internal adverse benefit determination by the plan concerning a claim involving urgent care, a description of the expedited review process applicable to such claims (g) Statement indicating you will be provided, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to your claim for benefits BYU-Idaho Student Health Plan 29

39 (h) In the case of an initial internal adverse benefit determination by the plan as subject to the Patient Protection and Affordable Care Act (ACA): You will be provided, upon request and free of charge, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning, and the notice will contain a statement to such effect. The plan must: Ensure any notice of initial internal adverse benefit determination includes information sufficient to identify the claim involved (including the date of service, health-care provider, and claim amount (if applicable) Ensure the reason or reasons for the initial internal adverse benefit determination includes the denial code and its corresponding meaning, as well as a description of the plan s standard, if any, used in denying the claim Provide a description of available internal appeals and external review processes, including information about how to initiate an appeal Disclose the availability of and contact information for any applicable office of health insurance consumer assistance or ombudsman established under Section 2793 of the Public Health Service Act to help individuals with the internal claims and appeals and external review processes Notices will be provided in a culturally and linguistically appropriate manner Appeals of Initial Internal Adverse Benefit Determination If you disagree with a claim determination after following the steps on page 27, you can contact Deseret Mutual in writing to formally request an appeal. In your appeal, you may submit written comments, documents, records, and other information relating to your claim for benefits. You will be provided, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to your claim for benefits. The review of your claims will take into account all comments, documents, records, and other information you submit, without regard to whether such information was submitted or considered in the initial benefit determination. With respect to a claim for benefits under the Student Health Plan, the plan will identify, upon request to Deseret Mutual, any medical or vocational experts whose advice was obtained on behalf of the plan in connection with your initial internal adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination. If the appeal relates to a claim for payment, your request should include: Patient s name and the identification number from the ID card Date(s) of health-care service(s) Provider s name Reason you believe the claim should be paid Any documentation or other written information to support your request for claim payment Claims Under the Student Health Plan The following appeals procedure will apply to claims made for benefits under the plan. You may appeal any denial of a claim within 12 months after you receive such a denial by submitting a written request for review to Deseret Mutual. The review of your appeal will not afford deference to the initial internal adverse benefit determination and will be conducted by an appropriate committee or named fiduciary of the plan who is neither the individual who made the 30 BYU-Idaho Student Health Plan

40 initial internal adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual. In deciding an appeal based in whole or in part on a medical judgment, including determinations about whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the appropriate committee or named fiduciary will consult with a health-care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who is neither an individual who was consulted in connection with the initial internal adverse benefit determination that is the subject of the appeal, nor the subordinate of any such individual. In the case of a claim under the plan involving urgent care, you are entitled to an expedited review process in which: You may submit a request for an expedited appeal of an initial internal adverse benefit determination orally or in writing; and All necessary information, including the plan s benefit determination on review, will be given to you by telephone, fax, or other available similarly expeditious method. Timing of Notification of Benefit Determination on Review For purposes of this section, the period within which a benefit determination on review is required to be made will begin at the time an appeal is filed without regard to whether all the information necessary to make a benefit determination on review accompanies the filing. If a period is extended as permitted on page 27 because you don t submit information necessary to decide a claim, the period for making the benefit determination on review will be tolled from the date the notification of the extension is sent to you until the date you respond to the request for additional information. Appeal Process A qualified committee or individual who was not involved in the decision being appealed will be appointed to decide the appeal. If your appeal is related to clinical matters, the review will be done in consultation with a healthcare professional with appropriate expertise in the field who was not involved in the prior determination. Deseret Mutual may consult with or seek the participation of medical experts as part of the appeal resolution process. You hereby consent to this referral and the sharing of pertinent health claim information. Upon request and free of charge you have the right to reasonable access to and copies of, all documents, records, and other information relevant to your claim for benefits. Appeals Determinations Pre-Service and Post-Service Claim Appeals You will be provided with written or electronic notification of the decision on your appeal as follows: For appeals of pre-service claims (see page 28), an internal appeal will be conducted and you will be notified by Deseret Mutual of the decision within a reasonable period appropriate to the medical circumstances, but not later than 15 days after receiving a request for appeal of a denied claim. If you aren t satisfied with the internal appeal decision of Deseret Mutual, you have the right to request an external review as described under Expedited External Review Request on page 35. For appeals of post-service claims (see page 28), the internal appeal will be conducted and you will be notified by Deseret Mutual of the decision within a reasonable period appropriate to the medical circumstances, but not later than 30 days after receiving a request for appeal of a denied claim. If you aren t satisfied with the internal appeal decision of Deseret Mutual, you have the right to request an external review as described under Standard External Review Request on page 34. For procedures associated with urgent care claims, see Urgent Care Claim Appeals That Require Immediate Action on page BYU-Idaho Student Health Plan 31

41 Please note, Deseret Mutual s decision is based only on whether or not benefits are available under the Student Health Plan for the proposed treatment or procedure. The determination as to whether the pending health service is right for you is between you and your doctor. Urgent Care Claim Appeals That Require Immediate Action Your appeal may require immediate action if a delay in treatment could significantly increase the risk to your health or the ability to regain maximum function or cause severe pain. In these urgent situations: The appeal does not need to be submitted in writing. You or your doctor should call Deseret Mutual as soon as possible. Deseret Mutual will provide you with a written or electronic determination within 72 hours after your request is received for review of the determination taking into account the seriousness of your condition. Deseret Mutual has the exclusive right to interpret and administer the provisions of the plan. Deseret Mutual s decisions are conclusive and binding. Deseret Mutual has final claims adjudication authority under the plan. Manner of Notification of Final Internal Benefit Determination Deseret Mutual will provide you with written or electronic notice of a plan benefit determination on review. If it is a final internal adverse benefit determination, the notice will set forth the following information, in a manner calculated to be understood by you, the participant: (a) Specific reason or reasons for the final internal adverse benefit determination (b) Reference to the specific plan provisions on which the final internal adverse benefit determination is based (c) Statement that you are entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant your claim for benefits (d) Statement describing any voluntary appeal procedures offered by the plan and your right to get the information about such procedures (e) In the case of the Student Health Plan: If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the final internal adverse benefit determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the final internal adverse benefit determination and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to you upon request If the final internal adverse benefit determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request The following statement: You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact the Idaho Department of Insurance. (f) Statement indicating that you will be provided, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to your claim for benefits (g) In the case of a final internal adverse benefit determination by the plan, as subject to the ACA: You will be provided, upon request and free of charge, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning, and the notice will contain a statement to such effect 32 BYU-Idaho Student Health Plan

42 The plan must: Ensure any notice of initial internal adverse benefit determination includes information sufficient to identify the claim involved (including date of service, health-care provider, and claim amount (if applicable) Ensure the reason or reasons for the final internal adverse benefit determination includes the denial code and its corresponding meaning, as well as a description of the plan s standard, if any, used in denying the claim Provide a description of available internal appeals and external review processes, including information about how to initiate an appeal Disclose the availability of and contact information for any applicable office of health insurance consumer assistance or ombudsman established under Section 2793 of the Public Health Service Act to help individuals with the internal claims and appeals and external review processes Notices will be provided in a culturally and linguistically appropriate manner General Rules Voluntary Extensions As described on pages 27 to 29, Deseret Mutual must decide your claim and/or appeal within certain timeframes, and Deseret Mutual may extend those timeframes in its discretion in certain circumstances. In addition, Deseret Mutual may request that you voluntarily agree to allow Deseret Mutual additional time extensions. You may allow or deny these additional voluntary extensions at your discretion. Rules Generally Applicable to Claims Under the Student Health Plan The following appeals procedure will apply to claims made for benefits under the plan as subject to the ACA and these default internal claims procedures. The plan must allow you to review the claim file and present evidence as part of the internal claims appeals process. The plan must provide you, free of charge, with any new or additional evidence considered, relied upon, or generated by the plan (or at the direction of the plan) in connection with your claim. Such evidence must be provided as soon as possible and sufficiently in advance of the date the notice of final internal adverse benefit determination is required to be provided to give you a reasonable opportunity to respond before that date. Before the plan can issue a final internal adverse benefit determination based on a new or additional rationale, you must be provided, free of charge, with the rationale. The rationale must be provided as soon as possible and sufficiently in advance of the date the notice of final internal adverse benefit determination is required to be provided to give you a reasonable opportunity to respond before that date. Authorized Representatives Any reference in these procedures to you or the participant is also a reference to your or the participant s authorized representative making a claim on your or his/her behalf. Deseret Mutual reserves the right to establish reasonable procedures for determining whether an individual has been authorized to act on your and/or the participant s behalf. Your Right to an Independent External Review Please read this notice carefully. It describes the procedure for review of a disputed health claim by a qualified professional who has no affiliation with your health plan. If you request an independent external review of your claim, the decision made by the independent reviewer will be binding and final on the health carrier, Deseret Mutual. Because the BYU-Idaho Student Health Plan is not subject to the Employee Retirement Income Security Act of 1974 (ERISA), you will not have the right to further review of your claim by a court, arbitrator, mediator, or other dispute resolution entity, as more fully explained under Binding Nature of the External Review Decision (see page 35) BYU-Idaho Student Health Plan 33

43 If we issue a final adverse benefit determination of your request to provide or pay for a health-care service or supply, you may have the right to have the decision reviewed by health-care professionals who have no association with Deseret Mutual. You have this right only if our denial decision involved: The medical necessity, appropriateness, health care setting, level of care, or effectiveness of your health-care service or supply, or Our determination that your health-care service or supply was investigational You must first exhaust the internal grievance and appeal process. This includes completing all levels of appeal or, unless you requested or agreed to a delay, our failure to respond in writing to a standard appeal within 35 days or to an urgent appeal within three business days of the date you filed your appeal. Deseret Mutual may also agree to waive the exhaustion requirement for an external review request. If your request qualifies as an urgent care request as defined on page 35, you may file for an internal urgent appeal with us and for an expedited external review with the Idaho Department of Insurance at the same time. You may submit a written request for an external review to: Idaho Department of Insurance Attention: External Review 700 W. State St., 3rd Floor Boise, Idaho For more information and for an external review request form: See the department s website at or Call the department at , or toll-free in Idaho at You may represent yourself in your request or you may name another person, including your treating health-care provider, to act as your authorized representative. If you want someone else to represent you, you must include a signed Appointment of an Authorized Representative form with your request. Your written external review request to the Department of Insurance must include a completed form authorizing the release of any of your medical records that the independent review organization may require to reach a decision. This includes any judicial review of the external review decision. The department won t act on your external review request without your completed authorization form. If your request qualifies for external review, Deseret Mutual s final adverse benefit determination will be reviewed by an independent review organization chosen by the department. Deseret Mutual will pay the costs of the review. Standard External Review Request: You must file your written external review request with the department within four months after Deseret Mutual issues a final notice of denial. 1. Within seven days after receiving your request, the department will send a copy to Deseret Mutual. 2. Within 14 days after Deseret Mutual receives your request from the department, we will review it for eligibility. Within five business days after completing that review, we will notify you and the department in writing if your request is eligible or if we need more information. If we deny your eligibility for review, you may appeal that determination to the department. 3. If your request is eligible for review, the department will assign an independent review organization to your review within seven days of receiving Deseret Mutual s notice. The department will also notify you in writing. 4. Within seven days of the date you receive the department s notice of assignment to an independent review organization, you may submit any additional information in writing that you want to be considered in the review to the independent review organization. 5. The independent review organization must provide written notice of its decision to you, to Deseret Mutual, and to the department within 42 days after receiving an external review request. 34 BYU-Idaho Student Health Plan

44 Expedited External Review Request: You may file a written urgent care request with the department for an expedited external review of a pre-service or concurrent service denial. You may file for an internal urgent appeal with us and for an expedited external review with the department at the same time. Urgent care request means a claim relating to an admission, availability of care, continued stay or health-care service for which the covered person received emergency services but has not been discharged from a facility, or any pre-service or concurrent care claim for medical care or treatment for which application of the time periods for making a regular external review determination: 1. Could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function, 2. In the opinion of the treating health-care professional with knowledge of the covered person s medical condition, would subject the covered person to severe pain that cannot be adequately managed without the disputed treatment, or 3. The treatment would be significantly less effective if not begun promptly. The department will send your request to Deseret Mutual. We ll determine, no later than the second full business day, if your request is eligible for review. Then we ll notify you and the department no later than one business day after our decision if your request is eligible. If we deny your eligibility for review, you may appeal that determination to the department. If your request is eligible for review, the department will assign an independent review organization to your review after receiving our notice. The department will also notify you. The independent review organization must provide notice of its decision to you, to Deseret Mutual, and to the department within 72 hours after receiving the external review request. The independent review organization must then provide written confirmation of its decision within 48 hours of notice of its decision. If the decision reverses Deseret Mutual s denial, we ll notify you and the department of our intent to pay the covered benefit as soon as reasonably practicable, but no later than one business day after receiving the decision. Binding Nature of the External Review Decision: The external review decision by the independent review organization will be final and binding on both you and the health carrier, Deseret Mutual. This means that if you choose to request external review, you ll be bound by the decision of the independent review organization. You won t have any further opportunity for review of our denial after the independent organization issues its final decision. If you choose not to use the external review process, other options for resolving a disputed claim may include mediation, arbitration, or filing an action in court. Under Idaho law, the independent review organization is immune from any claim relating to its opinion rendered, or acts or omissions performed within the scope of its duties, unless performed in bad faith or involving gross negligence. Definitions Accident: An unpremeditated event of violent and external means that happens suddenly without intention or design; is unexpected, unusual, unforeseen; is identifiable as to time and place; and is not the result of illness Acute: Having rapid onset, severe symptoms, and a short course; opposite of chronic Coinsurance: The percentage of eligible expenses you are responsible for paying after you make the applicable copayments and your plan benefits have been paid Congenital Anomaly: A condition existing at or from birth that is a significant deviation from the common form or function of the body, whether caused by a hereditary or developmental defect or disease. Significant deviation means a deviation that impairs the function of the body. It includes but is not limited to cleft lip, cleft palate, webbed fingers or toes, sixth toes or fingers, or defects of metabolism and other conditions that are medically diagnosed to be congenital anomalies. Contracted Facilities: Hospitals, labs, and other health-care facilities that have contracted with Deseret Mutual to provide services to participants BYU-Idaho Student Health Plan 35

45 Contracted Providers: Physicians, specialists, and other providers of health-care services who have contracted with Deseret Mutual to provide services to participants Copayment: The initial dollar amount you pay for an eligible medical expense at the time services are rendered Custodial Care: Maintaining a patient beyond the acute phase of injury or illness. Custodial care includes room, meals, bed, or skilled medical care in any hospital or extended care facility, or at home to help the patient with feeding, bowel and bladder care, respiratory support, physical therapy, administration of medications, bathing, dressing, ambulation, and so on. The patient s impairment, regardless of the severity, must require such support to continue for more than two weeks after establishing a pattern of this type of care Elective Surgery: Operations or surgical procedures for a condition that is not immediately life threatening and the timing is subject to the choice or decision of the patient and the physician Eligibility Date: The date you become eligible for benefits Eligible Charges / Expenses: Expenses incurred by you or a dependent for treatment of injury or illness and that are: Medically necessary for the care and treatment of the injury or illness and are incurred on the recommendation and while under the continuous care of a physician Not in excess of the maximum allowable charges defined by Deseret Mutual for the services performed or the materials furnished Not excluded from coverage by the terms of the plan Incurred for one or more of the services or materials specified in the plan Incurred during a period of active enrollment in the plan Eligible charges incur on the date the service is performed or the purchase is made Emergency Care: The care required in connection with a sudden and unexpected onset of a condition requiring medical or surgical care necessary to safeguard the patient s life immediately after the onset of the emergency. This includes heart attack, severe bleeding, loss of consciousness, convulsions, acute asthmatic attacks, or temperature of more than 104º Fahrenheit Extended Care Facility: An institution, or part of an institution, that is licensed pursuant to state or local law, and is operated primarily for the purpose of providing skilled nursing care and treatment for an individual convalescing from injury or illness as an inpatient Illness: A bodily disorder, disease, pregnancy, mental or emotional infirmity, or all sickness that is a result of the same cause or a related cause Inpatient: A patient who stays in a hospital while receiving medical care Matriculating Student: A student admitted to BYU-Idaho on one of the three regular enrollment tracks (fall-winter, winter-spring, spring-fall), or on the fast track enrollment option Maximum Allowable Charge (Limit): The maximum dollar amount Deseret Mutual will pay for a defined procedure Medical Equipment: A prosthesis, appliance, or device that is primarily and customarily used to serve a medical purpose and generally is not useful to a person in the absence of injury, illness, or congenital defect Medical Supply: Medical items that are for immediate use, are disposable, and are not reusable Medical Treatment: Therapeutic measure(s), including consultations, undertaken by or under the direction of a physician in connection with an injury or illness Non-contracted Facilities: Hospitals, labs, and other health-care facilities that have not contracted with Deseret Mutual to provide services to participants 36 BYU-Idaho Student Health Plan

46 Non-contracted Providers: Physicians, specialists, and other providers of health-care services that have not contracted with Deseret Mutual to provide services to participants Outpatient: A patient who receives treatment at a hospital, emergency room, or clinic, but who is not hospitalized Physician: A person who has been educated, trained and licensed as a physician to practice the art and science of medicine pursuant to the laws and regulations in the locality where the services are rendered Preauthorization: A process of advance notification that is required for a number of benefits. When you preauthorize services with Deseret Mutual, you receive guidelines about what services are eligible for benefits before you commit to the costs Residential Treatment Center for Mental Illness: A facility that is licensed by the state to provide residential treatment of mental illness that has licensed, clinical professionals providing specific treatment for either mental illness or chemical dependency Surgical Center: Any licensed public or private establishment: With an organized medical staff of physicians With permanent facilities equipped and operated primarily for the purpose of performing surgical procedures With continuous physician services whenever a patient is in the facility That does not provide services or other accommodations for patients to stay overnight Notice to Plan Participants Introduction University Insurance Requirement Changes for 2012 Prescription Benefit Preventive Services Extended Coverage Option Enrollment Enrolling Yourself Enrolling Your Family Changing Enrollment Midyear Waiving Enrollment Eligibility Coverage Coverage Options While You re Away from BYU-Idaho Away-from-Campus Coverage Option Extended Coverage Option Coverage Periods Coverage at Other Church Universities Premiums How the Plan Works Overview Insurance Identification Card Copayments and Office Visit Fees Plan Benefits and Coinsurance Maximum Plan Benefit Deductibles Preauthorization Student Health Center Available Services Payment for Services Operating Hours Services Outside of the SHC Deseret Mutual s Preferred Provider Network Emergencies Life-threatening Emergencies Other Medical Emergencies Follow-up to Emergency Care Submitting Claims for Payment Claims Payment Timelines Catastrophe Protection Repatriation of Remains Exclusions Subrogation Notification of Benefit Changes Fraud Policy Statement Legal Notice Important Dates Internal Claims Procedures Appeals of Initial Internal Adverse Benefit Determination Your Right to an Independent External Review Definitions Frequently Asked Questions Index BYU-Idaho Student Health Plan 37

47 Frequently Asked Questions Q A Q A Q A Q A Q A Q A Q A Q A Q A Why does Deseret Mutual the administer the Student Health Plan? In 1987, the Church Board of Education (chaired by the First Presidency) asked Deseret Mutual to create a Student Health Plan for all Church-owned universities. They were instructed to develop a plan that offers benefits just as good or better than those offered at other universities. Deseret Mutual is a not-for-profit entity. They do not pay commissions to agents or brokers to sell the plan. The Student Health Plan is a cost-effective insurance product with minimal overhead costs to handle claims. The Church Board of Education, BYU-Idaho, and Deseret Mutual review the benefits and premiums of the plan on a regular basis. Because of this, we believe the Student Health Plan sufficiently addresses medical costs for the vast majority of students. Why is the waiver policy so rigid? The waiver policy works to decrease the premium for students enrolled in the plan. Because Deseret Mutual is a notfor-profit organization, it has no incentive to enforce this policy except to benefit you. It makes sure that students are complying with BYU-Idaho s enrollment policies while providing the most cost-effective plan possible. Why do I need insurance? Without adequate coverage, unexpected medical expenses could alter your future dramatically. The costs of medical care and hospitalization continue to increase at an alarming rate. An accident, unexpected illness, or hospitalization could result in a significant financial burden to you, your family, and the community. As part of attendance at Church universities, students are required to maintain adequate health insurance. This requirement also applies to students who are off-track or serving in internships. I m off track. Do I still have to be enrolled in the Student Health Plan? Yes. Enrollment in the Student Health Plan is on an annual basis. This means you must be enrolled in the plan during both on-track and off-track semesters. I have other insurance. Can I waive the Student Health Plan? BYU-Idaho will allow you to waive the plan if you have insurance through your employment, your spouse s employment, or your parent s employment. Otherwise, you must be enrolled in the Student Health Plan. It s my first time enrolling in the Student Health Plan. What do I need to do? Nothing. You will be enrolled in the plan automatically when you register for classes. I had private insurance, but I need to switch to the Student Health Plan. What should I do? For help to enroll, contact the Student Health Center. You must provide proof of the termination of your other insurance coverage. What are the plan benefits? Please see the Student Health Plan handbook online at Or you may call Deseret Mutual at Does the plan cover specialty (or high-cost) pharmacy, dental, or eyewear costs? No. Covering these costs would inflate premiums and make the plan unaffordable for the vast majority of students. However, the Student Health Center pharmacy offers low-cost pharmaceuticals, including commercial generic medication, oral contraceptives, and over the counter medications. The pharmacy can also educate you about available resources for lower prices on typically high-cost drugs. 38 BYU-Idaho Student Health Plan

48 Q A Q A Q A Q A Q A Q A Q A Q A Q A Q A Will my coverage by the Student Health Plan automatically renew? Yes. Coverage automatically renews each semester. This includes any semesters off track. Will my waiver of coverage automatically renew? No. You must fill out a waiver each semester to verify your insurance status when enrolling for classes. I will be serving an internship this semester. Am I still covered by the Student Health Plan? Yes. Even if you re away from the Rexburg area, you still have coverage. As part of attendance at Church universities, students are required to maintain adequate health insurance. This requirement also applies to students who are off-track or serving internships. How do I pay premiums for the Student Health Plan? Your student account will be charged for premiums. Premium is due at the same time as tuition for each semester or block. The deadline for enrollment in the Student Health Plan is at the same time. Refunds are not granted after that date. I just got married. Do I need to let you know? Yes. Your premium and benefits change when you get married. For a summary of these changes, please see the Student Health Plan handbook at Will the plan cover my wife s maternity costs? If she is a full-time student, your wife will have maternity coverage after she meets the $750 married student deductible. If your wife is not a full-time student and is enrolled as a dependent on your plan, she is covered for all maternity charges exceeding $5,500. (That is, she must meet the $750 married student deductible and the $4,750 non-student spouse maternity deductible.) I just had a baby. Is my baby automatically covered by my insurance? No. You must contact the Student Health Center insurance personnel within 60 days of birth or adoption to enroll your baby. I m graduating but want to remain enrolled in the Student Health Plan. How do I keep my coverage? Contact the Student Health Center insurance personnel to enroll in the Extended Coverage plan. You may enroll in Extended Coverage for up to 90 consecutive days after your last day of coverage. I want to end my Student Health Plan coverage. What do I need to do? If you are graduating or leaving school permanently, your coverage will end automatically. If you enroll in the Student Health Plan and then obtain other coverage that meets BYU-Idaho s requirements, you may discontinue your enrollment in the Student Health Plan at the beginning of the next semester or block. To do so, submit an online waiver at before the beginning of the semester or block. Or you can complete a form and submit it to the Student Health Center insurance personnel. What does the Safe Harbor notice at the front of this handbook mean? I thought the recent health-care reform required plans to cover contraceptives. Contraceptives have consistently remained an exclusion of your Student Health Plan. For questions related to BYU-Idaho s application for Safe Harbor and the University s response to the contraceptive mandate, please call the BYU-Idaho Student Health Center at BYU-Idaho Student Health Plan 39

49 INDEX Accident Acute After-hours emergencies iv Allergy services Ambulance Anesthesia Annual deductible Away-from-campus coverage Beginning of coverage Benefit changes , 25 Catastrophe protection Chemotherapy Claims, payment of Claims, review procedures , 30, 33 Congenital anomaly Coinsurance , 35 Contact information (telephone, , address) iii Contracted facilities Contracted providers Copayment , 36 Hospitalization , 11 Maternity care , 13 Services at the SHC Services outside of the SHC Coverage options Coverage periods Custodial care Dates and deadlines Deductibles Definitions Dental accident benefit BYU-Idaho Student Health Plan

50 Dependents Diabetes education Diabetic supplies Dialysis Elective surgery Eligibility Eligibility date Eligible charges Emergency , 20, 36 Ending of coverage Enrollment Away-from-Campus Changes Extended Exclusions Extended care facility Extended coverage Eye exams Family medicine Fraud Frequently asked questions Graduation or change of status Hearing testing Home health care Hospital Emergency Inpatient Maternity , 13 Illness Inpatient Insurance identification card Internal medicine BYU-Idaho Student Health Plan 41

51 Laboratory services , 11 Leaving BYU-Idaho Mammography Maternity Student Non-student spouse Matriculating student Maximum allowable limit Maximum plan benefit Medical equipment , 36 Medical supplies , 36 Medical treatment Mental health Missionary service Non-contracted facilities Non-contracted providers Office visit fee Office visits Orthopedics Outpatient Pain clinics Pediatrics Pharmacy , 16 Physical exams Physical therapy Physician Physician services Inpatient Maternity , 13 Office visits SHC Surgery BYU-Idaho Student Health Plan

52 Plan benefit Preauthorization , 37 Preferred Provider Network Premarital exams Premiums Prescription drugs Preventive services , 16, 17 Prosthetics Radiation therapy Radiology services Repatriation of remains Residential treatment center Services at other university health centers Student Health Center (SHC) Copayments , 9 Hours Services Subrogation Substance abuse Summary of benefits v, vi Surgery Outpatient Inpatient Physician services Surgical center Telephone numbers iii Urgent care (walk-in clinic) Waiving enrollment Well-baby care Women s Health & Cancer Act X-rays BYU-Idaho Student Health Plan 43

53